Furious Seasons

January 04, 2008

Atypical Nation: Placebo Beats Anti-Psychotics In Treating Aggression

You read that headline correctly. A study out in The Lancet today asserts that among a group of 86 non-psychotic patients with low IQs given either Risperdal, Haldol or a placebo to stem their irritability and aggressive outbursts placebo outperformed the two anti-psychotics. Although the study involved a group of patients for whom I don't know their particular DSM diagnosis, this is major news, perhaps heralding the end of the common use of anti-psychotics in Western culture.

First, it completely overlaps with the results of the CATIE study of anti-psychotic use in the elderly where placebo beat anti-psychotics, as I reported in November. Second, it speaks loud and clear to the status of kids, especially young boys, with ADHD and bipolar disorder who are being given anti-psychotics to control aggressive behavior. Third, it speaks to the use of these drugs in adults with bipolar disorder who are mostly being given these drugs to quell agitation. Fourth, it clearly has implications for the treatment of people with autism (Autism Vox takes up some of those questions here). Fifth, it has important implications for the emerging paradigm of treating depression with anti-psychotics.

The New York Times has the most extensive coverage of the study so far and clearly gets that the implications of this study are vast:

"'This is a very significant finding by some very prominent psychiatrists'--one that directly challenges the status quo, said Johnny L. Matson, a professor of psychology at Louisiana State University in Baton Rouge, co-author of an editorial with the study in the journal Lancet.
"While it is unclear how much the study by itself will alter prescribing habits, 'the message to doctors should be, think twice about prescribing, go with lower doses and monitor side effects very carefully,' Dr. Matson continued, adding:

“'Or just don’t do it. We know that behavioral treatments can work very well with many patients.'"

So why did the patients do better with a placebo?

"Being in the study, with all the extra attention it brought, was itself what apparently made the difference, he [a study author] said.
"'These people tend to get so little company normally,' Dr. Tyrer said. 'They’re neglected, they tend to be pushed into the background, and this extra attention has a much bigger effect on them that it would on a person of more normal intelligence level.'"

I'll have more thoughts on this study later, but let me be clear that its findings cannot necessarily be extrapolated to the treatment of psychosis. But the study authors dropped this bomb at the end of their article:

"Antipsychotic drugs should no longer be regarded as an acceptable routine treatment for aggressive challenging behaviour in people with intellectual disability."

Permit me a moment of gloating, please. For over two years, this site has been committed to seeing a sea change in the widespread use of anti-psychotics in our culture because it was clear to me that they didn't work very well in treating either psychosis or aggression. What's more, I wrote a lengthy article in Seattle Weekly two years ago in which I attacked the use of anti-psychotics in bipolar disorder and the stupidity of doctors in going along for the ride in creating a $14 billion market for these drugs. A lot of people have criticized me very aggressively for my views and have questioned my intellectual abilities and psychological stability in the process.

To them, I say: I was right. You were wrong. And the evidence of just how wrong you have been keeps mounting in study after study. If you wish to debate this matter further, then let's find a time and a place to do so. And soon. There are children and vulnerable people being doped on these drugs each day in America and elsewhere and they merit our attention.

For patients, I would recommend that you make your doctor aware of this study. If they fail to take its findings into account in your treatment, then you need to find another doctor.

Posted by Philip Dawdy at January 4, 2008 11:52 AM

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Comments

Philip, your site does more for me than my shrink!

Posted by: susan at January 4, 2008 12:07 PM

This is absolutely unbelievable, I think every single psychiatrist and PCP should have this in front of them. I also agree, that true psychosis, schizophrenia shouldn't be lumped in with this --because I have witnessed Clozaril bring my daughter back from a bad place, to not perfect, but better place in her life.

The danger of anti psychotic use is there, and to use those drugs for anything else, is plain criminal.

Congratulations for nailing this down, and yes, you are right and they were wrong and anyone who wants to debate it, most likely never took an anti psychotic drug to know what they are speaking.

Posted by: Stephany at January 4, 2008 12:24 PM

perhaps heralding the end of the common use of anti-psychotics in Western culture.

that's awfully optimistic, but god I hope you're right!

Posted by: Gianna at January 4, 2008 12:49 PM

A year and a half ago Seroquel, albeit at a low dose of 25-75 mg, was prescribed to me for sleep!

That it surprisingly, to my pdoc, completely controlled agonizing intrusive thoughts and attendant anxiety was a welcome bonus.

My issue, though, is why on earth did it not occur to him to try it for the thoughts and anxiety I was having, and was far more debilitating, than the lack of sleep I was getting on the ward.

Completely skewed thinking on his part.

Posted by: Cairn at January 4, 2008 02:15 PM

I thought that this piece was quite interesting, when I read it, last night. However, I've had the opportunity to read the NYT piece properly, this morning, and was delighted to find the following quotation:

"...Janssen, a Johnson & Johnson subsidiary, said that Risperdal only promotes approved uses, which in this country include the treatment of irritability associated with autism in children..."

To which I would like to offer the following counterpoint:

http://www.arkansasnews.com/archive/2007/11/21/News/344126.html

What a bunch of liars these people are!

Matt

Posted by: Matthew Holford at January 5, 2008 04:25 AM

I am really surprised the study was published and reported on.

Posted by: mark p.s. at January 5, 2008 07:15 AM

In the interests of legal propiety, I should point out that it is not a fact that Janssen are a bunch of liars, (particularly given that the Arkansas civil case has not been decided) merely that that is my opinion, which I am still permitted to have, under the western common law system of justice.

Matt

Posted by: Matthew Holford at January 5, 2008 12:35 PM

I agree with Matt's opinion, which is also, just an opinion.

Posted by: Stephany at January 5, 2008 05:54 PM

Does anyone really believe facts will sway the psychiatric establishment and its supporters?

Posted by: Alison Hymes at January 6, 2008 01:27 PM

Hey Dr. Dawdy,

I stumbled upon your blog while doing some internet research. I am a recent college grad and long-time writer who finally got the courage to start a bipolar blog. The address is unevenpieces.blogspot.com.

I hope to eventually develop the site into a forum for exploring the link between creativity and "madness" - basically taking "touched with fire" and transforming it into a user-generated site (post-secret meets myspace).

Anyway, I'm hoping to stake a piece of real estate on your links section - and I would be honored to do the same for you. Check out the site and let me know.

Thanks,

Matt Bradley
Hamilton '07

Posted by: Matt Bradley at January 6, 2008 04:30 PM

Alison,

"Does anyone really believe facts will sway the psychiatric establishment and its supporters?"

Nope. This is a billion dollar industry, with lots of vested interests in many sectors of society - even if it wanted to, psychiatry wouldn't be allowed to change. As I mentioned to Aubrey Blumsohn, a while ago: I'm just going for ritualized humiliation, now, because I bet I can come up with more whacky ideas than they can!

Matt

Posted by: Matthew Holford at January 6, 2008 07:00 PM

What is the expedient answer then, to treating aggressive behavior?

What alternatives are there in this day and age of declining hospital beds and insurance companies that pay for medical visits but not therapy?

What advice would you give to the parents of a 6', 200lb bipolar teenager who has beaten up his stepfather, taken a hammer to the family car and whose siblings have been diagnosed with PTSD?

Do these people take out a second mortgage on their home to pay for one of the unregulated "camps for troubled teens" or wait until he's done something significant enough to land him in the criminal justice system?

In the joke that is "mental health parity," HMO carve-outs have conspired to pay fewer benefits, not more for the severly mentally ill. How are people to otherwise survive this nightmare?

Posted by: Sm3 at January 14, 2008 07:03 AM